GENERAL AND HEALTH CARE POWER OF ATTORNEY

OF

NAME
I, NAME., residing at , execute this General Power of Attorney with the intention
that the Attorney-in-Fact (“Agent”) named shall be able to act in my place in all matters and I
intend that it is governed by the District of Columbia.

SECTION 1. DESIGNATION OF AGENT AND ALTERNATE AGENT

1.1 I, NAME, appoint my son NAME to be my Agent for this my POWER OF

ATTORNEY.

1.2. In the event that____________________, is unable to serve as my Power of Attorney,

Agent in fact then I appoint my______________, as my Alternate/Second Agent for this my
POWER OF ATTORNEY.

1.3. In this document, whether my Agents are referred to as masculine, feminine or neuter,
as well as singular and plural, I intend to refer to the above mentioned Agents.

SECTION 2. EFFECTIVE DATE OF POWER OF ATTORNEY

2.1. This Power of Attorney shall be effective immediately upon the date of execution.

2.2. All persons dealing with my Agent may fully rely on this General and Health Care
Power of Attorney and the authority to act for me unless I have actual knowledge of its
revocation or of my death.

2.3. If no Agent designated in this document is available or able to serve, I request that my
desires as expressed in this document be given full effect as a written expression of my intent.

SECTION 3. INTENTION

3.1. My Agent is authorized in his sole and absolute discretion to exercise the powers set
forth in this document relating to matters involving my legal, health and medical care. In
exercising such powers, he should try to discuss with me the specifics of any proposed decision
regarding my medical care and treatment. My Agent is further instructed that if I am unable to
give an informed consent to a proposed medical treatment, he shall give, withhold, withdraw, or
modify such consent for me based upon any preferences that I have expressed while competent,
whether under this document or otherwise. I desire my Agent to seek consultation, if he deems
necessary, nevertheless, my Agent’s power is not contingent upon his consulting with me.

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SECTION 4. GENERAL POWERS
My Agent shall have the following powers:

4.1. To request and review any information, oral or written, regarding legal (such as,
including but not limited to: bank accounts, medical records, mortgage statements, veteran
affairs, disability, social security, car insurance, etc.), physical or mental health, including
medical and hospital records.

4.2. To employ and discharge medical personnel as my Agent shall deem necessary for my
physical, mental, and emotional wellbeing and to arrange for medical personnel to be paid
reasonable compensation.

4.3. To give or withhold consent to any medical procedure, test, or treatment including
surgery and psychiatric treatment; to arrange for my hospitalization, convalescent care, hospice,
home care, or emergency treatment, as he shall deem appropriate.

4.4. If he determines that the benefits of any medical procedures, tests, or treatments are
outweighed by the burdens imposed, to revoke, withdraw, modify, or change consent to such
procedures, tests, and treatments as well as to hospitalization, convalescent care, hospice, or
home-care which my Agent may have previously allowed.

4.5. To consent to and arrange for the administration of pain-relieving drugs of any kind or
other surgical or medical procedures calculated to relieve pain, including unconventional pain-
relief therapies which my Agent believes may be helpful, even though such drugs or procedures
may have adverse side effects, may cause addiction, or may hasten the moment of (but not
intentionally cause) my death as he shall deem appropriate.

4.6. To execute contracts, consents, waivers, releases, or any and all other documents for any
medical provider caring for me or rendering opinion about my care.

LIVING WILL
SECTION 5. SPECIAL POWERS REGARDING LIFE-SUSTAINING TREATMENT

Notwithstanding the other provisions in this document, the Agent is to make health care
decisions for me based on the health care instructions I give in this document, the Living Will
Provision and my wishes as otherwise known to our Agent. If my wishes are unknown or
unclear, my Agent is to make health care decisions for me in accordance with our best interests,
to be determined by my Agent after considering the benefits, burdens, and risks that might
result from a given treatment or course of treatment.

5.1. I do not wish to receive medical treatment which will postpone the moment of my death
from an incurable and terminal condition or prolong an irreversible coma.

5.2. For purposes of this document, “terminal condition” shall refer to a condition that is
reasonably expected to result in our death, regardless of the treatment that we may receive, and
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“irreversible coma” shall refer to a permanent loss of consciousness from which there is no
reasonable probability that we will regain the use of my mental faculties.

5.3. Upon the occurrence of the conditions specified in Section 2.1 – 2.2, we direct that:

(a) If my death from a terminal condition is imminent and even if life-sustaining

procedures are used and there is no expectation of my recovery, I direct that my life
not be extended OR extended for _______ months by: surgery, cardio-pulmonary
resuscitation, mechanical ventilation, dialysis, antibiotics, artificial nutrition and
hydration, therapy, chemotherapy, radiation and other forms of medical treatment
which stimulate or maintain vital bodily functions.

(b) If I am in a persistent vegetative state, that is, if I am not conscious and are not
aware of our environment or able to interact with others, and there is no reasonable
expectation of recovery, I direct that my life not be extended: surgery, cardio-
pulmonary resuscitation, mechanical ventilation, dialysis, antibiotics, artificial
nutrition and hydration, therapy, chemotherapy, radiation and other forms of medical
treatment which stimulate or maintain vital bodily functions.

(c) If I have an end-stage condition, that is a condition caused by injury, disease, or

illness, as a result of which I have suffered severe and permanent deterioration
indicated by incompetency and complete physical dependency and for which, to a
reasonable degree of medical certainty, treatment of the irreversible condition would
be medically ineffective, I direct that my life not be extended by life-sustaining
surgery, cardio-pulmonary resuscitation, mechanical ventilation, dialysis,
antibiotics, artificial nutrition and hydration, therapy, chemotherapy, radiation and
other forms of medical treatment which stimulate or maintain vital bodily functions.

(d) If I are in a coma, I direct that my life not be extended by life-sustaining procedures,
including, but not limited to: surgery, cardio-pulmonary resuscitation, mechanical
ventilation, dialysis, antibiotics, artificial nutrition and hydration, chemotherapy,
radiation and other forms of medical treatment which stimulate or maintain vital
bodily functions.

(e) In addition to our choices, as designated above, regarding the acceptance, refusal or
withdrawal of medical treatment, I specifically direct that sufficient medication be
administered to relieve pain and discomfort, without regard to whether or not the
doses required will hasten death.

5.4. In making any decision under this Section, my Agent should consider whether the
treatment will relieve suffering or improve prognosis, the intrusiveness of the treatment, the
risks and side effects involved, whether it will extend life and, if so, what enjoyment of life will
be able to have thereafter.

5.5. Notwithstanding the powers given my Agent under this Section, he/she shall follow any
other subsequent instructions, oral or written, that I give him/her while I am competent.
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5.6. I intend that this Living Will be honored in any jurisdiction where it may be presented
to interpret it and determine its validity. In this jurisdiction Living Will is synonymous with
Advanced Medical Directive and/or Directives Concerning Life.

SECTION 6. GENERAL LEGAL PROVISIONS

The following additional provisions shall apply to this document:

6.1. Generally, to exercise full control over any and all of my real property and financial
property, such as bank accounts, mortgages, social security, 401ks, pensions, Medicare and
Medicaid, including but not limited to the rights to manage, control, operate, improve, transfer,
sell, mortgage, lien destroy and dispose of said property absolutely in any manner that the
Attorney may in their absolute discretion see fit and without any obligation to give reasons or
justification as if the said assets were the property of the Attorney absolutely.

6.2. My Agents are authorized to execute, deliver, govern, review, interpret, determine, serve
and any such powers over all mortgage accounts, mortgage statements, mortgage documents
and shall make any decisions necessary over my mortgage loan obligations both past and
current.

6.3. To receive, call upon, recover, collect and otherwise take the benefit of any and all
income or capital benefit from any and all of my property including but not limited to trading
income, passive income of any source, rental income, income from dividends, shares, income
from employment, pensions, trust, annuities, bequests, legacies and from any other property as
if that income and capital were the property of the Attorney absolutely and without any
obligation to give reasons or justification for their actions.

6.4. To agree, negotiate and make any agreement, promise or undertaking concerning my
property with any third party whether written or not and on such terms and for such
consideration as the Attorney may in their absolute discretion, see fit.

6.5. To settle and make payment of any and all debts, taxes, charges, professional fees and
other obligations or liabilities due to me whether by payment of cash or by the transfer,
assignment or sale of my property.

6.6. To sign and execute on my behalf any and all documents and formalities which the
Attorney in their absolute discretion considers to be necessary to or conducive to the execution
of any of the powers set out in this general power of attorney including but not limited to the
executing and signing of deeds, contracts, agreements, declarations, and mortgages.

6.7. To sue or bring other legal action on my behalf against any third-party for whatever
reason the Attorney may in their absolute discretion see fit and to settle said legal action by any
means the Attorney may see fit including the making and accepting of out of court settlements.

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6.8. To appear in my name and in my stead before any competent court and legal or public
authority including but not limited to all national and federal tax authorities.

6.9. My Agents are authorized to execute, deliver, govern, review, interpret, determine, serve
and any such powers over all financial matters where my name is attached thereto, including
but not limited to: bank accounts, checking accounts, saving accounts, debtor, mortgagor, bill
recipient and borrower, etc.

6.10. My Agents are authorized to execute, deliver, and acknowledge any document that may
be necessary or desirable to exercise any of the powers described in this document and to incur
reasonable costs in the exercise of any such powers. In addition, my agent shall cause bills in
connection with any health care rendered pursuant to this document to be sent to the Agent then
serving as my Power of Attorney. I direct and consent that such bills be paid, if such is
possible.

6.11. My Agents is specifically authorized to sue on our behalf and at my expense for
appropriate relief, including damages, against any person who fails to honor this General and
Health Care Power of Attorney.

6.12. My Agents shall not be held legally responsible for debts, bills, law suits, medical bills,
mortgages, etc. My Agent has authority to act as my legal representative but will not assume
any debt responsibilities.

6.13. My Agents shall be entitled to reimbursement for all reasonable expenses actually
incurred and paid by him/her on my behalf under any provision of this document, but my Agent
shall not be entitled to compensation for services rendered.

6.14. I retain the right to revoke or amend in writing this document and to substitute other
Agents. Any amendment to this document shall be witnessed and attached to the original of
this document.

6.15. My Agents shall have no liability or responsibility whatsoever for any action taken
under this document so long as he acts in good faith.

6.16. Photocopies of the General and Health Care Power of Attorney shall have the same
force as the original. All persons shall be protected in relying on the original or a photocopy of
this General and Health Care Power of Attorney (plus any additional documents described
above, as appropriate) as proof of the authority granted to a person serving as Agent.

6.17. I intend that this General and Health Care Power of Attorney be honored in any
jurisdiction where it may be presented to interpret it and determine its validity.

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SECTION 7. STATEMENT TO SIGNOR

I CERTIFY THAT (A) I HAVE READ THE PROVISIONS OF THIS SECTION

DIRECTING MY AGENT TO REFUSE OR TO ADMINISTER MEDICAL TREATMENT
FOR ME UNDER THE CIRCUMSTANCES SPECIFIED IN THIS DOCUMENT; (B) THESE
PROVISIONS HAVE BEEN EXPLAINED TO ME AND TO MY SATISFACTION, (C) I
UNDERSTAND THESE PROVISIONS, AND (D) THEY ACCURATELY STATE MY
WISHES.

In witness whereof, I have set my hands and seal this____ day of _____________, 2018.

_________________________________
NAME

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DISTRICT OF COLUMBIA

On this the ________ day of __________________, 2018, before me, the undersigned,
a notary public in and for said County and State, personally appeared, known to me (or proved
to me on the basis of satisfactory evidence) to be the person(s) whose names are subscribed to
the within instrument (General and Health Care Power of Attorney for NAME) and
acknowledged to me that they executed the same in their authorized capacities, and that by their
signatures on the instrument the persons, or entity upon behalf of which the persons acted, and
executed the instrument.

WITNESS my hand and official seal.

____________________________________ Signature of Notary

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